Nokea
The nurse is caring for a client with a history of rheumatoid arthritis who is receiving prednisone 10 mg PO daily. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue.
- B. Weight gain of 5 pounds in a month.
- C. Occasional joint stiffness.
- D. Mild headache.
Correct Answer: B
Rationale: Weight gain of 5 pounds in a month suggests prednisone-induced fluid retention, requiring evaluation. Options A, C, and D are less urgent.
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A client is scheduled for a traditional abdominal cholecystectomy.
Which of the following statements, if made by the nurse to the client the night before surgery, is MOST important?
- A. It is important for you to eat foods from every level of the food pyramid and avoid excessive fats in your diet.'
- B. Place the pillow against your abdomen, take three deep breaths, hold your breath, and then cough two or three times.'
- C. There will be a machine available to you after surgery for you to use to continuously receive pain medication.'
- D. You may come back from surgery with a tube in your nose that drains your gall bladder.'
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each implementation. Is it desired? (1) not most important initially, teaching should be done before discharge (2) correct-should be done every two hours to prevent respiratory complications, splinting prevents abdominal jarring (3) PCA pumps used postoperative but medication is administered intermittently (4) NG tube used to drain stomach, T-tube used to drain common bile duct
When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse’s actions during this intervention?
- A. The restraints/seclusion policies set forth by the institution.
- B. The patient’s competence.
- C. The patient’s voluntary/involuntary status.
- D. The patient’s nursing care plan.
Correct Answer: C
Rationale: The need for restraints is based on the patient’s behavior and safety risks, not their voluntary or involuntary admission status. Institutional policies, patient competence, and the care plan guide restraint use to ensure safety and compliance with legal and ethical standards.
The nurse is caring for an older adult in his home. Which of the following factors increase the client's risk for falls? Select all that apply.
- A. The client is 78 years old.
- B. The home is a one-story home.
- C. There are several scatter rugs on the hardwood floors.
- D. The client's wife does all of the housework.
- E. There are handrails in the bathroom.
- F. There are several plants in the living room.
Correct Answer: A,C,F
Rationale: Age over 65, scatter rugs, and obstacles like plants increase fall risk. A one-story home, handrails, and the wife's housework reduce risk.
The nurse is caring for a client who is postoperative day 1 after a mastectomy. Which of the following actions should the nurse prioritize?
- A. Encourage arm exercises on the affected side.
- B. Administer pain medication as needed.
- C. Monitor the surgical drain for output.
- D. Check the incision for redness.
Correct Answer: A
Rationale: Arm exercises prevent lymphedema and promote mobility post-mastectomy. Options B, C, and D are secondary.
A client preparing for surgery.
Which of the following statements by the client BEST indicates to the nurse an emotional readiness for surgery?
- A. I know the doctor isn't telling me everything, but at this point I can't do anything about it.'
- B. I've never heard of this specialist before. Does he do much work here?'
- C. I'm glad the trapeze is on my bed so I can start working on my exercises as soon as I wake up.'
- D. Can you please check my record to be sure it says I'm diabetic?'
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) indicates feelings of fear and helplessness (2) indicates fear and lack of trust (3) correct-indicates acceptance and a readiness to participate in postoperative care (4) indicates fear that something will be missed